White Paper: Strength Training for the Older Adult

Dale Avers PT, DPT, PhD;1 Marybeth Brown, PT, PhD, FAPTA, FACSM2
1

Post-professional DPT Program, SUNY Upstate Medical University, Syracuse, NY

2
University of Missouri, Columbia MO

ates the recidivism seen in many therapy settings where a former

patient falls or sustains further functional decline requiring additional episodes of PT care.

Exercise to remediate impaired endurance, joint dysfunction, and impaired mobility is a mainstay of physical therapy
practice for older adults.1 Common modes of exercise include
aerobic, strengthening, and balance/flexibility programs. In
the past 20 years, much has been learned about the benefits
of strengthening.2-5 Muscle weakness, termed sarcopenia6
and dynapenia7, is a normal age-related phenomenon, occurring at a rate of 1% to 5% annually from the age of 30.8 This
rate means that given typical patterns of physical activity, a
70-year-old woman could have 50% to 70% less strength than
she had at age 30. The rate of strength decline is dependent
on age and physical activity. Those who are physically inactive lose muscle mass and strength more quickly than active
individuals who participate in strength training.9 After the age
of 60, power decreases even more rapidly at a rate of 3% to
5% annually, affecting the ability to move and react quickly.10
Diminished power and strength affect function and can be
a leading cause of nursing home admission and falls, further
reinforcing sedentary habits.9,11 The vicious cycle of inactivity
and diminished power and strength in turn promote further
weakness and loss of power causing further functional disability. Critical to keeping older adults independent in the community and avoiding nursing home placement is breaking this
cycle of decreased muscle mass/strength/power, inactivity, and
functional decline. Therefore, effective strengthening practices
must be employed by physical therapy personnel to maintain
the highest level of function and achieve optimal aging.

Exercise Prescription
Muscle Strength
The American Academy of Sports Medicine, the American
Geriatrics Society, the Section on Geriatrics of the American
Physical Therapy Association, and others have recommended
the use of a 60% or higher of a 1RM strength stimulus to improve strength and function, even for those with pathology such
as osteoarthritis or congestive heart failure.13,15-17 While the exact
dosage in terms of intensity, sets, repetitions, and frequency has
not been fully determined, solid evidence is available to physical
therapists caring for aging adults.18
Intensity
Sixty percent of a 1-RM is the minimal overload necessary for muscle adaptation in untrained individuals, including
older adults.19 This threshold can be determined using the rate
of perceived exertion scale (Table 1) or the maximum number
of repetitions the person can perform. The maximum number
of repetitions occurs when exercising muscle fatigues, almost
reaching failure as indicated by deteriorating form and inability
to complete full range during the last 1 to 2 repetitions. Muscle
fatigue just before failure indicates a maximal level of exertion
and should be achieved for optimal strengthening to occur.13 A
60% threshold equates to 15 repetitions and a rate of perceived
exertion (RPE) of 12-13. Greater strength effects are achieved
Table 1. Rate of Perceived Exertion
Modified
Scale

The Minimum Stimulus: Overload

Muscle requires an adequate stimulus, or overload, to get
stronger.12 Similar to the cardiovascular system, skeletal muscle
requires a workload of approximately 60% of maximum available strength to increase in strength.13 For some older adults
this overload stimulus may be as low as the weight of a grapefruit; for others, overload may be the weight equivalent of a
loaded grocery bag. Threshold is most commonly based on a
1 repetition maximum, (1-RM) or the ability to lift or perform
a movement 1 time and 1 time only before muscle fatigue prevents lifting of the load or performing movement through full
range of motion.13 Some practitioners use a 3-RM or 8-RM to
determine level of overload depending on perceived frailty and
safety.
Activities and exercises below the 60% threshold may result
in a modest improvement of 5% to 10% on strength tests, but
the observed change is likely related to motor learning rather
than a biological increase in contractile protein in the muscle.14
Motor learning alone does not achieve a reversal of muscle atrophy. Without overload, a further decline in function is likely
once intervention ceases. This focus on emphasizing motor
learning (eg, gait training without muscle overload) often cre

Percent
Effort

20%

30%

40%

50%

10

55%

11

60%

12

65%

13

70%

14

75%

15

80%

16

85%

17

90%

18

95%

19

100%

10

20

Exhaustion

148

Ordinal
Scale1

Perceived
Work Load
Very, very
light

Very light
Fairly light

Talk Test
At Rest
Gentle walking
or strolling
Steady pace, not
breathless

Moderately
hard

Brisk walking,
able to carry on a
conversation

Hard

Very brisk
walking, must
take a breath
between 4-5
words

Very hard
Very, very
hard

Unable to talk
and keep pace

Journal of Geriatric Physical Therapy Vol. 32;4:09

with higher intensities of 80% of a 1-RM (15-17 RPE) even in

the very old and frail.20-22 The 80% threshold equates to 10
repetitions, where form deterioration is observed in the last 1
to 2 repetitions.
To determine the appropriate resistance stimulus for
strengthening, a quantitative baseline level of strength must be
determined. Estimating the amount of resistance an individual can move based on body weight is one option, especially for
the leg press and bench press.13 For a women over 60 years of
age, the 50% percentile for the bilateral leg press is equal to a
1-RM of her body weight.13 Body weight, then, is an estimate
of starting weight for determining appropriate load, and resistance load is increased or until the woman can push the load
through the full range only one time (1-RM).
If pain or high joint forces are a concern, the 10-RM method is another option for determining appropriate resistance
for strengthening. The 10-RM method uses 80% of a 1-RM as
a starting point: the individual is asked to lift 80% of her body
weight through full range and with good form as many times
as possible. Rather than creating an artificial target by asking
for a set number of repetitions, asking for as many repetitions
as possible minimizes underestimation of the repetition maximum. If more than 20 repetitions can be completed with good
form, the chosen resistance is below the 60% threshold necessary for strengthening and needs to be increased.13
Similarly, a functional movements quantitative baseline
can be determined. The aging adult can be asked to perform a
step up without using his/her arms. If this is too difficult for
an individual to accomplish independently, the task can be
modified by using a lower step, or allowing use of the arms (although it will be difficult to determine how much of the load
is borne by the legs when arm use is allowed). If more than
one step up is possible, load can be increased either by raising
step height or using a weighted vest for incremental increases
in load, such that 1-RM or 10-RM can be determined and sufficient overload is assured. This method of determining appropriate workload can be applied to many functional activities,
including sit to stand transitions, wall slides, and transfers.
The traditional manual muscle test (MMT) does not effectively estimate workload for strengthening because of a profound ceiling effect: a 5/5 MMT grade spans forces from 76
675 Newtons.23 Many therapists are unable to consistently
discern the difference in muscle function between a MMT
grade of Good (4/5) vs. Normal (5/5): measurement error
with MMT may be as high as 50%.24 In addition, a MMT
grade of 5/5 does not accurately reflect strength necessary
for functional activities. Eriksrud and Bohannon found the
minimum lower extremity strength necessary to rise from a
chair without arm assistance is 40% to 47% of a persons body
weight, equating to a 5/5 grade for the quadriceps on one side
and 4+/5 grade on the other using the MMT scale.25 If strength
is graded as 4/5 and 5/5 or within functional limits without
examining performance of functional activity, important impairments of muscle performance will not be identified.
When beginning a strengthening program for aging adults
with physical and functional frailty, using a load just below the
desired threshold for overload will insure good form and allow
opportunity for motor learning of the specific movement of the
exercise.18 Between 15 to 20 repetitions with evidence of muscle
Journal of Geriatric Physical Therapy Vol. 32;4:09

fatigue just prior to failure is appropriate in teaching the aging

adult the exercise protocol in the first week of the program.26
One week is often sufficient time for consistency in performance to develop; once the routine is mastered, the resistance is
increased exercise to load that will stimulate muscle adaptation
(ie, a minimum of 60% 1RM).
Sets
The American College of Sports Medicine (ACSM ) and
others recommend that for untrained individuals, a minimum
threshold of 1 set be performed when an adequate strength
stimulus is used.2,13 Greater strength gains are realized when
more sets are performed, although risk of injury may increase
with multiple sets.13 In the clinic, use of a single set of each
exercise during a physical therapy session allows performance of
a variety of exercises and movements, is more interesting to the
client, and has lower risk of overuse injury.
Repetitions per Set
The number of repetitions should be determined based on
the desired intensity for strengthening (Table 2). The appropriate number of repetitions is determined by the patients effort
and form, rather than an arbitrary target number named by
the therapist. Direction to perform 10 repetitions may underestimate what the aging adult is capable of, such that he/she
does not reach minimal threshold for strengthening. When the
number of repetitions is estimated based on the repetition maximum, the minimum 60% of the individuals 1-RM is more
likely to be achieved. Asking the patient/client to perform the
movement as many times as possible while observing for signs
of deteriorating form will more accurately achieve the appropriate stimulus for strengthening.
Frequency
The recommended frequency of exercise performance is
based on muscle recovery. When intensity to promote muscle strength (60% or more of 1RM) is used, recommended
frequency is 2-3x/week, allowing 24 to 48 hours of rest in
between sessions of the same muscle group.13,26 If a patient
receives physical therapy care more than once daily over 5-7
days/week, focusing on different muscle groups in each session
is necessary to allow adequate muscle rest (ie, upper extremities are challenged one day, lower extremities are challenged
the next day). An example of a weekly schedule incorporating
recommended rest for muscle recovery is found in Table 3.
Long lasting and significant change in strength occurs
over a 12 to 16 week period; however in most instances, aging
adults are discharged from physical therapy care in hospital
and rehabilitation settings before such gains can be realized.
For this reason, home exercise programs and/or community
based exercises are necessary if goals of gaining and maintaining strength are to be successfully met.
Where home exercise programs (HEP) are used, specific
strengthening exercises performed in the clinic are adapted to
make muscle challenge realistic. Milk jugs filled with water,
sand filled containers, and elastic bands such as Theraband(R)
etc. can provide sufficient stimulus to continue strengthening
begun in the clinical setting. Each HEP should be designed to
include adequate time for muscle recovery, similar to the way
149

Table 2a. How to Determine Intensity with 1-RM as the

Starting Value

Table 2b. How to Choose a Weight or Machine Value Given

a 1-RM of 100 Pounds

Desired
Baseline

% of
1-RM

Desired
Baseline

Load
(in pounds)

Repetitions

1-RM

100

1-RM

100

2-RM

95

2-RM

95

3-RM

93

3-RM

93

4-RM

90

4-RM

90

5-RM

87

5-RM

87

6-RM

85

6-RM

85

7-RM

83

7-RM

83

8-RM

80

8-RM

80

9-RM

77

9-RM

77

10-RM

75

10-RM

75

10

RM = repetition maximum

Table 2c. Appropriate Loads (in pounds) for a Variety of 1-RM Values
1-RM

2-RM

3-RM

4-RM

5-RM

6-RM

7-RM

8-RM

9-RM

10-RM

10

10

20

19

19

18

17

17

17

16

15

15

30

29

29

27

26

26

25

24

23

23

50

48

47

45

44

43

42

40

39

38

70

67

65

63

61

60

58

56

54

53

120

115

112

108

105

103

100

96

93

91

150

143

140

135

131

128

125

120

116

113

Example: If a 78-year old man can leg press 120 pounds (1-RM) and the desired training intensity is 60% of 1-RM for the first two weeks of exercise, his maximum load would be .60 x 120= 72 lbs. One repetition of this
load would be appropriate to lift for 60% of 1-RM. If ten repetitions are desired, the load would be 60 pounds.

Table 3. Example of Exercise Schema to Incorporate Appropriate Intensity and Rest in the Inpatient Environment
Exercise:

Monday

Tuesday

Wednesday

Thursday

Friday

Strengthening
High Intensity

Dorsiflexors
Quadriceps
Gluteus maximus
Gluteus medius
Gastrocnemius

Abdominals
Erector spinae

Dorsiflexors
Quadriceps
Gluteus maximus
Gluteus medius
Gastrocnemius

Abdominals
Erector spinae
Measure 10-RM or RPE

Dorsiflexors
Quadriceps
Gluteus maximus
Gluteus medius
Gastrocnemius
Measure 10-RM or RPE

Work on gait speed

Measure Gait Speed

Gait tolerance
Measure endurance
(i.e. 6MWT)

Work on gait speed

Gait tolerance

Work on gait speed

Postural Control
& Balance

Static balance
Dynamic Balance
Stability Ball

Dynamic gait:
Head turning, obstacle
course, uneven and
compliant surfaces

Static balance
Dynamic Balance
Stability Ball
Measure Balance (i.e.
BBS)

Dynamic gait:
Head turning, obstacle
course, uneven and
compliant surfaces

Static balance
Dynamic Balance
Stability Ball

Task-specific
Activity
High Intensity

ADLs, transfers, bed

mobility, wheel chair
mobility; timed or
weighted

Reaching, squatting,
bending, lifting,
rotation, etc; timed or
weighted

ADLs, transfers, bed

mobility, wheel chair
mobility; timed or
weighted

Reaching, squatting,
bending, lifting, rotation,
etc; timed or weighted

ADLs, transfers, bed mobility,

wheel chair mobility; timed or
weighted

Endurance
Ambulation

(Footnotes)
1 Adapted from Borg Perceived Level of Exertion

exercises are designed in the clinical setting. Performing the

same strengthening exercises at an intensity of 60% of 1-RM
twice a day is not appropriate based on muscle physiology. To
provide adequate muscle rest, the HEP might also include motor learning activities and/or aerobic activity.

Muscle Power
The ability to accelerate and to move quickly is an important
component of muscle performance that is often compromised
in older adults.27 Adequate power is necessary to cross the street,
to climb stairs, and to quickly rise from a chair. Diminished abil150

Journal of Geriatric Physical Therapy Vol. 32;4:09

the number of repetitions the patient can do safely, with good

form and with maximum muscle fatigue just prior to failure
should be re-established.26 Other ways of progressively increasing the stimulus is to perform more sets or multiple exercises for
the same muscle group.

ity to respond quickly to loss of balance, related to diminished

power, has been implicated as a cause of falls.28 Because improving power can reduce falls and function,29 improving power is
a necessary element of a strengthening program. Once an older
adult achieves 2 sets of an exercise/movement with good form
and no pain, it is appropriate to incorporate training to increase
power resources in their exercise program.26,30 The goal is to
move as quickly as possible through the concentric phase of the
exercise, followed by a slow and controlled lowering of the load
through the eccentric phase back to starting position.29 Initial
loads of 20% of 1RM are progressed as tolerated (indicated by
good form and no pain), increasing toward 60% of 1RM.26,30

Injury
Many authors have demonstrated the safety of high intensity exercise.5,35,36 However, some authors have suggested that the
potential for injury indicates the need for supervision by trained
personnel.37,38 It is our opinion that using high intensity resistance
requires one-on-one supervision to observe form and muscle fatigue. Additionally, adverse cardiac events have not been reported
in patients undergoing high intensity training.39-41 In fact, cardiac benefits are more likely to occur. For example, Martel et al
reported decreases in blood pressure in older adults with high
normal blood pressures after performing high intensity exercise
training.42 Delayed onset muscle soreness (DOMS) is a common
effect of high intensity strength training and should be expected.
The therapist can minimize the effects of DOMS by preparing
the patient/client for its effect, specifically identifying the location of the expected muscle soreness and differentiating muscle
soreness from joint pain. Encouraging the patient/client to move
through the DOMS will reduce the duration of DOMS.

Specificity and Functional Strength

Training
Strengthening occurs in the specific way that muscle is
trained. Sale et al found that closed chain training on a leg
press did not increase strength in open-chain knee extension
performance and vice versa.14 In designing exercise programs
for aging adults, consideration must be given to salient activities
and tasks, especially if there is limited functional reserve or little
desire to exercise. Tasks that can be compromised by inadequate
strength include transfers, stair climbing, mobility, and activities
of daily living that tax dynamic balance. Interventions focusing
on developing strength enough to safely and efficiently do these
tasks receive priority. Because these tasks involve weight bearing in multiple planes, activities that promote stepping, weight
shifting and multi-planar movements should be emphasized.
Examples include rising from surfaces of different heights, foot
tapping various height steps and progressing to stepping up and
over steps and stair climbing, stooping, kneeling, and reaching.
Once these tasks can be accomplished with good form, adding
a weighted vest to increase load or increasing speed of movement will provide the necessary overload to continue building
strength in ways specific to the task.
For frail individuals, task specificity may be the critical parameter to improve function, rather than intensity, because of
diminished reserve and increased bodily fatigue.31 De Vreede,32
Bean,33 and Manini34 have demonstrated that when frail individuals perform task specific exercise, their strength is increased,
similar to the effects of resistance exercise. The performance of
certain ADL and household tasks in frail individuals may require enough effort to achieve the threshold required for muscle
strengthening, thus combining overload with motor learning
to achieve functional improvements. Task-specific training for
frail men and women may achieve functional gains better than
resistance exercise alone.32

Clinical Significance
Muscle weakness is related to decreased physical function
and falls and is a compelling reason for physical therapy intervention. However, inadequate resistance is too often seen in the
clinic where 2lb weights are commonly used and an arbitrary
number of repetitions to perform is given, without a quantitative baseline assessment of strength. Strengthening without rationale or adequate stimulus is tantamount to malpractice.
SUMMARY
The aim of this White Paper was to review the current recommendations for strength training of older adults, to promote
physical therapist best practice and achieve optimal functional
outcomes. A secondary intent was to encourage prospective researchers to use published guidelines to establish an adequate
strength stimulus for patients in their research, rather than perpetuating usual or traditional care.
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Journal of Geriatric Physical Therapy Vol. 32;4:09

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